Ovarian Stimulation in Patient-oriented Strategies Encompassing Individualised Oocyte Number-4 Category; Antagonist versus Short-agonist Protocols.

Background: Recently POSEIDON (Patient-Oriented Strategies Encompassing Individualized Oocyte Number) classification was proposed to categorize patients with expected poor response to conventional stimulation. Searching for the ideal management of poor responders in IVF is still an active research area. Aims: This study compares GnRH-antagonist and GnRH-agonist short protocols in ICSI cycles for the POSEIDON-4 group. Settings and Design: This retrospective study was conducted in a tertiary infertility unit between January 2016 and December 2020. Materials and Methods: Infertile women who met the criteria for POSEIDON 4 group and underwent fresh ICSI-ET in using GnRH-antagonist and GnRH-agonist short protocols was performed. POSEIDON-4 includes patients ≥ 35 years with poor ovarian reserve markers; AFC < 5 and AMH < 1.2 ng/ml. Statistical Analysis Used: Numerical variables were compared between both groups by student's t test and Mann Whitney test when appropriate. Chi-square test used to compare categorical variables. Multivariate logistic regression models were utilized to adjust for the effect of the different study confounders on live birth rate. Results: One hundred ninety fresh ICSI cycles were analyzed. Of the total cohort, 41.6 % (79) patients pursued antagonist protocol compared to 58.4% (111) underwent short agonist protocol. Fresh embryo transfer was accomplished in 55.7 % (44/79) vs. 61.3 % (68/111), P = 0.44 in antagonist vs. short protocol respectively. Cycle cancellation due to poor ovarian response was encountered in (32.9%vs. 27.9%, P = 0.50) in the antagonist and short groups, whereas no good-quality embryos were developed after ovum pickup in 11.4% vs. 10.8%, P>0.05. Comparable total gonadotropins dose, number of retrieved and mature oocytes, and good-quality embryos were found in both groups. Likewise, clinical pregnancy rate was not different for the antagonist and short groups [11/79 (13.9%) vs. 20/111 (18%), P = 0.45]. The live birth rate was comparable between both groups (8.9% vs. 10.8%, P = 0.659) for antagonist and short groups respectively. No significant impact for the protocol type on live birth rate was revealed after adjusting to cycle confounders in multivariate analysis (OR: 0.439, 95%CI 0.134-1.434, P = 0.173). Conclusion: This study shows comparable pregnancy outcomes for antagonist and short-agonist protocols in IVF/ICSI cycles for POSEIDON-4 category.

The rate of SARS-CoV-2 among asymptomatic non-immunised low-risk parturient women between the two waves.

This study was conducted to evaluate the rate of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and immunity among asymptomatic non-immunised low-risk parturient women and their newborns. A cross-sectional study conducted in a tertiary hospital during the nadir period of new cases in Egypt. All asymptomatic pregnant, low risk and non-immunised women were included. All eligible participants had been subjected to SARS-CoV-2 nasopharyngeal swabs according to CDC and sampling of maternal and umbilical blood to evaluate the presence of coronavirus disease 2019 (COVID-19) IgM and IgG antibodies by immunochromatographic assay. Two cases out of 171 (1.2%) parturient women were tested positive for PCR swab to COVID-19 infection. Furthermore, COVID-19 IgG and IgM antibodies testing showed that 67.8% of women were negative for both IgG and IGM, 24.6% were positive for IgG only, 4.1% were positive for IgM only, while 3.5% were positive for both IgG and IgM. Regarding neonatal testing for immunity, 28.1% of the neonates were positive to IgG only and none for IgM.The rate of positive PCR patients among asymptomatic low-risk parturient women was 1.2%. About quarter of women had got herd immunity as evident by positive IgG antibodies. IgG antibodies transferred to the neonates in almost all cases.Impact StatementWhat is already known on this subject? Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a global public health emergency. Asymptomatic pregnant women with coronavirus disease can transmit their infection to their newborn, family members and the health care providers.What do the results of this study add? The study showed very low (1.2%) prevalence of COVID positive cases among asymptomatic pregnant women admitted to our facility. Only two cases out of 171 parturient women tested PCR positive for COVID-19 infection (1.2%). SARS-Cov-2 IgG and IgM antibodies testing showed, about a quarter (24.6%) were positive for IgG antibodies, 4.1% were positive for IgM antibodies, while 3.5% were positive for both IgG and IgM. On the other hand, 28.1% of the neonates were positive to IgG only and none of the newborns had had IgM antibodies in their cord blood.What are the implications of these findings for clinical practice and/or further research? The first wave of COVID-19 pandemic in Egypt left behind at least a quarter of pregnant women with a positive antibody denoting some immunity. This immunity is usually transmitted to the neonates in almost all cases.

The Impact of High Circulating Anti-Müllerian Hormone on Endometrial Thickness and Outcome of Assisted Reproductive Technology in Women with Polycystic Ovarian Syndrome: A Cohort Study.

Background: Elevated circulating anti-Müllerian hormone (AMH) in women with the polycystic ovarian syndrome (PCOS) has been found to have a detrimental effect on endometrial function. This may adversely affect the outcome of in vitro fertilisation (IVF) in PCOS women. Aims: To investigate the impact of high serum AMH concentrations on endometrial thickness (ET) and the outcome of IVF in women with PCOS. Settings and Design: This retrospective cohort study included all PCOS women who underwent fresh IVF\intracytoplasmic sperm injection cycles between January 2016 and December 2021 in one major IVF centre. Materials and Methods: PCOS diagnosis was based on Rotterdam criteria, and participants were identified from centre database. All women received antagonist protocol. Primary outcomes were trigger-day ET and live birth rate (LBR). Circulating AMH was correlated with ET and ovarian response. Statistical Analysis Used: AMH levels were compared between women with and without live birth. ET and LBRs were compared between women with AMH <7.0 ng/ml versus those with AMH ≥7.0 ng/ml. Results: The study included 102 PCOS women, of which six were excluded due to poor response (n = 4), hyperresponse (n = 1) or fertilisation failure (n = 1). Of the remaining 96 women, 42 (43.8%) achieved a live birth. There was no statistically significant (P > 0.05) correlation between AMH and ET. Mean ± standard deviation AMH concentration was not significantly (P > 0.05) different between women with live birth (6.5 ± 3.4 ng/ml) and those without (6.5 ± 2.4 ng/ml). High AMH positively correlated with the number of oocytes retrieved, metaphase II oocytes and embryos (P = 0.003, 0.006 and 0.006, respectively). There was no statistically significant (P > 0.05) difference in ET or LBR between women with AMH <7.0 ng/ml (n = 72; ET, 10.7 ± 1.8 mm; LBR, 45.8% [33/72] versus those with AMH ≥7.0 ng/ml (n = 24; ET, 10.8 ± 1.7 mm; LBR, 37.5% [9/24]). Conclusions: High circulating AMH in PCOS women does not seem to negatively affect ET or LBRs during assisted reproductive technology.

Intrauterine injection of HCG before embryo transfer: a parallel, double-blind randomized trial.

RESEARCH QUESTION: Does intrauterine administration of HCG before embryo transfer improve live birth rate during IVF cycles? DESIGN: A parallel, randomized controlled trial conducted between July 2018 and February 2020. Infertile women (n = 181) scheduled for fresh or vitrified-warmed embryo transfer after IVF carried out for any indication were randomized in a 1:1 ratio to receive either HCG (500 IU in 0.1 ml of tissue culture media) or culture media (0.1 ml of tissue culture media) via intrauterine injection 4 min before embryo transfer. In both groups, an intrauterine insemination catheter was used for administering the medication. Primary outcome was live birth, with ongoing pregnancy and clinical pregnancy as secondary outcomes. Analysis was based on intention-to-treat principle. RESULTS: Baseline and cycle characteristics were comparable between the two groups. In the control group, one woman with a confirmed clinical pregnancy was lost to follow-up. Live birth rates were 24% (22/90) in the HCG group versus 19% (17/90) in the control group (RR 1.29, 95% CI 0.74 to 2.27). Clinical pregnancy and ongoing pregnancy rates were 34% versus 26% (RR 1.31, 95% CI 0.84 to 2.04) and 24% versus 19% (RR 1.29, 95% CI 0.74 to 2.27) in the HCG and the control groups, respectively. CONCLUSION: Intrauterine injection of HCG before embryo transfer did not improve live birth rates in women undergoing IVF. As the study was designed to detect a 20% difference between groups, a smaller, clinically important difference could not be ruled out. Treatment outcomes were lower than expected in the control group.

Assessment of Circulating Anti-Müllerian Hormone in Women Using Hormonal Contraception: A Systematic Review.

Background: The status of ovarian reserve markers during hormonal contraception (HC) remains uncertain with conflicting literature data. The purpose of this study was to assess the impact of HC on circulating anti-Müllerian hormone (AMH) and other ovarian reserve markers. Materials and Methods: A systematic review was conducted, including all cohort, cross-sectional, and randomized controlled studies assessing serum anti Müllerian hormone concentration in women using HC. Data sources included MEDLINE, EMBASE, DynaMed Plus, ScienceDirect, TRIP database, ClinicalTrials.gov, and the Cochrane Library from January 2000 to October 2018. Results: A total of 366 studies were identified, of which 15 were eligible, including 3280 women, mostly using combined HC (CHC). Articles were divided according to duration of HC into short- (2-3 weeks), medium- (2-6 months), long- (>1 year), and varied-term studies. Two study designs were identified, including studies comparing AMH before and during/after CHC and studies comparing CHC users versus nonusers. Short- and medium-term studies (n = 284) reported no change in circulating AMH in women using cyclical CHC for one to six cycles. Apart from one study, all long- and varied-term studies (six studies, n = 1601) consistently showed a marked decline in AMH, antral follicle count, and ovarian volume. Three long-term studies (n = 1324) provided evidence of AMH recovery after discontinuation of HC. Conclusion: Circulating AMH seems to remain unchanged in women using cyclical CHC for up to 6 months, but appears to markedly decline in long-term users with recovery after discontinuation.

Repeated recovery of immature oocytes in a woman with a previous history of empty follicle syndrome.

The empty follicle syndrome (EFS) is defined as a failure to aspirate any oocyte (s) from the follicles after ovarian hyperstimulation in preparation for IVF/ICSI. It is a frustrating and vague syndrome; and a controversial one concerning its existence, causes and possible treatment. Recurrent EFS or the recovery of immature oocytes thereafter is a more challenging problem. Delayed injection after leaving the immature oocytes for in vitro-maturation (IVM) has been suggested to be a possible option if immature oocytes are retrieved. Here, we present a case of repeated retrieval of a few immature oocytes after a first incidence of EFS. IVM was tried twice for those immature oocytes. Unfortunately, in this case IVM was unsuccessful and the oocytes failed to mature in vitro. Assistance is required for future management of these unfortunate couples.

The effect of follicullar fluid pesticides and polychlorinated biphenyls concentrations on intracytoplasmic sperm injection (ICSI) embryological and clinical outcome.

OBJECTIVES: The present study evaluated the correlation between the concentrations of polychlorinated biphenyls (PCBs) and pesticides in the follicular fluid (FF) obtained during intracytoplasmic sperm injection (ICSI) with the ovarian response, endometrial thickness, and embryological and clinical outcomes. DESIGN: Cross-sectional observational study. MATERIALS AND METHODS: Women aged 20 to 38 years (300 infertile couples) presenting to a university-affiliated fertility center were approached to participate in the study. Only 150 couples that underwent ICSI for male factor infertility agreed to participate, and 94 of them had retrieved enough FF samples suitable for laboratory testing. The FF sample was obtained, centrifuged, and stored in liquid nitrogen. Two organochlorine pesticides (OCPs), Lindane and DDT;three organophosphates (OPs);chlorpyrifos;Diazinon; malathion; one Chloroacetanilide (Pretilachlor);two pyrethroids(Bioallethrin and ß-cyfluthrin); and the concentrations of four PCBs, 28, 52, 138, 180, were estimated in the obtained FF samples by using gas chromatography/mass spectrometry. SPSS statistical analysis program (version 17) was used for analysis. Multiple regression analysis was used to correlate the PCBs and pesticides with ICSI outcomes. RESULTS: There were significant negative correlations between FF concentrations of the eight examined pesticides and the four PCBs on the endometrial thickness. However, Pretilachlor, chlorpyrifos, ß-cyfluthrin, and Diazinon were the only toxic agents that negatively correlated with the number of the oocytes retrieved. Fertilization and early embryo cleavage rates were negatively correlated with Pretilachlor and ß-cyfluthrin. Moreover, high concentrations of Lindane,DDT, Diazinon,and chlorpyrifos were significantly associated lower implantation rate. PCB 28 and 180 concentration in the FF was associated with a lower number of retrieved oocytes and fertilization rate, respectively. The number of implanted embryos was negatively correlated with PCB 52 FF concentration. However, the clinical pregnancy rate did not reach the level of significance. CONCLUSION: Higher concentrations of any studied PCBs and pesticides are associated with thinner endometrial thickness. The higher the level of Pretilachlor, ß-cyfluthrin, PCB 28 and 180, the lower the retrieval, fertilization, and embryo cleavage rates. High PCB and pesticide concentrations in the FF adversely affected embryological ICSI outcomes. However, more data are needed to evaluate their effect on the clinical outcome.

Ovarian reserve after salpingectomy: a systematic review and meta-analysis.

INTRODUCTION: Although there has been a growing concern over the possible damaging effect of salpingectomy on ovarian reserve, this issue remains uncertain. The purpose of this meta-analysis was to test the hypothesis that salpingectomy may compromise ovarian reserve. MATERIAL AND METHODS: A detailed search was conducted using MEDLINE, Embase, Dynamed Plus, ScienceDirect, TRIP database and the Cochrane Library from January 2000 to November 2016. All cohort, cross-sectional and randomized controlled studies investigating changes in circulating anti-Müllerian hormone (AMH) after salpingectomy were considered. Thirty-seven studies were identified, of which eight were eligible. Data were extracted and entered into RevMan software for calculation of the weighted mean difference (WMD) and 95% CI. Two groups of studies were analyzed separately: group 1 (six studies, n = 464) comparing data before and after salpingectomy and group 2 (two studies) comparing data in women who have undergone salpingectomy (n = 169) vs. healthy controls (n = 154). RESULTS: Pooled results of group 1 studies showed no statistically significant change in serum AMH concentration after salpingectomy (WMD, -0.10 ng/mL; 95% CI -0.19 to 0.00, I2 = 0%). Similarly, meta-analysis of group 2 showed no statistically significant difference in serum AMH concentration between salpingectomy group and controls (WMD, -0.11 ng/mL; 95% CI -0.37 to 0.14, I2 = 77%). Subgroup analyses based on laterality of surgery, type of AMH kit and participants' age (<40 years) still showed no statistically significant changes in circulating AMH. CONCLUSION: Salpingectomy does not seem to compromise ovarian reserve in the short-term. However, the long-term effect of salpingectomy on ovarian reserve remains uncertain.

Multifactorial contributors to the severity of chronic pelvic pain in women.

BACKGROUND: Chronic pelvic pain affects ∼15% of women, and is associated with significant societal cost and impact on women's health. Identifying factors involved in chronic pelvic pain is challenging due to its multifactorial nature and confounding between potential factors. For example, while some women with endometriosis have chronic pelvic pain, there may be comorbid conditions that are implicated in the chronic pelvic pain rather than the endometriosis itself. OBJECTIVE: We sought to explore multifactorial variables independently associated with the severity of chronic pelvic pain in women. STUDY DESIGN: We used baseline cross-sectional data from an ongoing prospective cohort, collected from patient online questionnaires, physical examination, and physician review of medical records. Participants were recruited from a tertiary referral center for endometriosis and chronic pelvic pain in Vancouver, British Columbia, Canada, from December 2013 through April 2015. Exclusion criteria included menopausal status or age >50 years. Primary outcome was self-reported severity of chronic pelvic pain in the last 3 months (0-10 numeric rating scale). Potential associated factors ranged from known pain conditions assessed by standard diagnostic criteria, validated psychological questionnaires, musculoskeletal physical exam findings, as well as pain-related, reproductive, medical/surgical, familial, demographic, and behavioral characteristics. Mann-Whitney, Kruskal-Wallis, or Spearman test were used to identify variables with an association with the primary outcome (P < .05), followed by multivariable linear regression to control for confounding and to identify independent associations with the primary outcome (P < .05). RESULTS: Overall, 656 women were included (87% consent rate), of whom 55% were diagnosed with endometriosis. The following factors were independently associated with higher severity of chronic pelvic pain: abdominal wall pain (P = .005), pelvic floor tenderness (P = .004), painful bladder syndrome (P = .019), higher score on Pain Catastrophizing Scale (P < .001), adult sexual assault (P = .043), higher body mass index (P = .023), current smoking (P = .049), and family history of chronic pain (P = .038). Severity of chronic pelvic pain was similar between women with and without endometriosis. CONCLUSION: Multifactorial variables independently associated with severity of chronic pelvic pain were identified, ranging from myofascial/musculoskeletal, urological, family history, and psycho-social factors. Continued research is required to validate these factors and to determine whether any are potentially modifiable for the management of chronic pelvic pain.

The impact of excision of benign nonendometriotic ovarian cysts on ovarian reserve: a systematic review.

BACKGROUND: Benign nonendometriotic ovarian cysts are very common and often require surgical excision. However, there has been a growing concern over the possible damaging effect of this surgery on ovarian reserve. OBJECTIVE: The aim of this metaanalysis was to investigate the impact of excision of benign nonendometriotic ovarian cysts on ovarian reserve as determined by serum anti-Müllerian hormone level. DATA SOURCES: MEDLINE, Scopus, ScienceDirect, and Embase were searched electronically. STUDY DESIGN: All prospective and retrospective cohort studies as well as randomized trials that analyzed changes of serum anti-Müllerian hormone concentrations after excision of benign nonendometriotic cysts were eligible. Twenty-five studies were identified, of which 10 were included in this analysis. DATA EXTRACTION: Two reviewers performed the data extraction independently. RESULTS: A pooled analysis of 367 patients showed a statistically significant decline in serum anti-Müllerian hormone concentration after ovarian cystectomy (weighted mean difference, -1.14 ng/mL; 95% confidence interval, -1.36 to -0.92; I(2) = 43%). Subgroup analysis including studies with a 3-month follow-up, studies using Gen II anti-Müllerian hormone assay and studies using IOT anti-Müllerian hormone assay improved heterogeneity and still showed significant postoperative decline of circulating anti-Müllerian hormone (weighted mean difference, -1.44 [95% confidence interval, -1.71 to -1.1; I(2) = 0%], -0.88 [95% confidence interval, -1.71 to -0.04; I(2) = 0%], and -1.56 [95% confidence interval, -2.44 to -0.69; I(2) = 22%], respectively). Sensitivity analysis including studies with low risk of bias and excluding studies with possible confounding factors still showed a significant decline in circulating anti-Müllerian hormone. CONCLUSION: Excision of benign nonendometriotic ovarian cyst(s) seems to result in a marked reduction of circulating anti-Müllerian hormone. It remains to be established whether this reflects a real compromise to ovarian reserve.

No evidence for mutations in NLRP7 and KHDC3L in women with androgenetic hydatidiform moles.

OBJECTIVE: The objective of this study was to evaluate the mutational spectrum of NLRP7 and KHDC3L (C6orf221) in women with sporadic and recurrent androgenetic complete hydatidiform moles (AnCHM) and biparental hydatidiform moles (BiHM) to address the hypothesis that autosomal recessive mutations in these genes are only or primarily associated with BiHM. METHOD: We recruited 16 women with suspected recurrent and sporadic AnCHM and five women with suspected BiHM in addition to their reproductive partners into our study. We then sequenced the coding exons of NLRP7 and KHDC3L from DNA isolated from either blood or saliva from the study subjects. RESULTS: Sequence analysis of NLRP7 and KHDC3L revealed previously described single nucleotide polymorphisms in patients with AnCHM. However, in patients with BiHM, we identified a novel homozygous mutation and a previously described intragenic duplication of exons 2 to 5 in NLRP7, both of which are likely to be disease causing. We did not identify mutations in KHDC3L in patients with either form of hydatidiform moles. CONCLUSIONS: The absence of mutations in women with AnCHM supports a role for NLRP7 or KHDC3L in BiHM only. The absence of mutations in KHDC3L in women with BiHM is consistent with its minor role in this disease compared with NLRP7, the major BiHM gene.

Obstetric hemorrhage and shock management: using the low technology Non-pneumatic Anti-Shock Garment in Nigerian and Egyptian tertiary care facilities.

BACKGROUND: Obstetric hemorrhage is the leading cause of maternal mortality globally. The Non-pneumatic Anti-Shock Garment (NASG) is a low-technology, first-aid compression device which, when added to standard hypovolemic shock protocols, may improve outcomes for women with hypovolemic shock secondary to obstetric hemorrhage in tertiary facilities in low-resource settings. METHODS: This study employed a pre-intervention/intervention design in four facilities in Nigeria and two in Egypt. Primary outcomes were measured mean and median blood loss, severe end-organ failure morbidity (renal failure, pulmonary failure, cardiac failure, or CNS dysfunctions), mortality, and emergency hysterectomy for 1442 women with ≥750 mL blood loss and at least one sign of hemodynamic instability. Comparisons of outcomes by study phase were assessed with rank sum tests, relative risks (RR), number needed to treat for benefit (NNTb), and multiple logistic regression. RESULTS: Women in the NASG phase (n = 835) were in worse condition on study entry, 38.5% with mean arterial pressure <60 mmHg vs. 29.9% in the pre-intervention phase (p = 0.001). Despite this, negative outcomes were significantly reduced in the NASG phase: mean measured blood loss decreased from 444 mL to 240 mL (p < 0.001), maternal mortality decreased from 6.3% to 3.5% (RR 0.56, 95% CI 0.35-0.89), severe morbidities from 3.7% to 0.7% (RR 0.20, 95% CI 0.08-0.50), and emergency hysterectomy from 8.9% to 4.0% (RR 0.44, 0.23-0.86). In multiple logistic regression, there was a 55% reduced odds of mortality during the NASG phase (aOR 0.45, 0.27-0.77). The NNTb to prevent either mortality or severe morbidity was 18 (12-36). CONCLUSION: Adding the NASG to standard shock and hemorrhage management may significantly improve maternal outcomes from hypovolemic shock secondary to obstetric hemorrhage at tertiary care facilities in low-resource settings.

Can the Non-pneumatic Anti-Shock Garment (NASG) reduce adverse maternal outcomes from postpartum hemorrhage? Evidence from Egypt and Nigeria.

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality and severe maternal morbidity. The Non-pneumatic Anti-Shock Garment (NASG), a first-aid lower-body compression device, may decrease adverse outcomes from obstetric hemorrhage. This article is the first to report the effect of the NASG for PPH. METHODS: This pre-intervention/NASG study of 854 women was conducted in four referral facilities in Nigeria and two in Egypt between 2004-2008. Entry criteria were women with PPH due to uterine atony, retained placenta, ruptured uterus, vaginal or cervical lacerations or placenta accreta with estimated blood loss of ≥ 750 mL and one clinical sign of shock. Differences in demographics, conditions on study entry, treatment and outcomes were examined. The Wilcoxon rank-sum test and relative risks with 95% confidence intervals were calculated for primary outcomes - measured blood loss, emergency hysterectomy, mortality, morbidity (each individually), and a combined variable, "adverse outcomes", defined as severe morbidity and mortality. A multiple logistic regression model was fitted to test the independent association between the NASG and the combined severe morbidity and mortality outcome. RESULTS: Measured blood loss decreased by 50% between phases; women experienced 400 mL of median blood loss after study entry in the pre-intervention and 200 mL in the NASG phase (p < 0.0001). As individual outcomes, mortality decreased from 9% pre-intervention to 3.1% in the NASG phase (RR 0.35, 95% CI 0.19-0.62); severe morbidity decreased from 4.2% to 1%, in the NASG phase (RR 0.24, 95% CI 0.09-0.67). As a combination, "adverse outcomes," decreased from 12.8% to 4.1% in the NASG phase (RR 0.32, 95% CI 0.19-0.53). In a multiple logistic regression model, the NASG was associated with the combined outcome of severe maternal morbidity and mortality (OR 0.42, 95% CI 0.18-0.99). CONCLUSION: In this non-randomized study, in which bias is inherent, the NASG showed promise for reducing blood loss, emergency hysterectomy, morbidity and mortality associated with PPH in referral facilities in Egypt and Nigeria.

A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Egypt.

OBJECTIVE: To assess the impact of the non-pneumatic anti-shock garment (NASG) on maternal outcome following severe obstetric hemorrhage. METHODS: A non-randomized pre-intervention/intervention study was conducted in 2 tertiary hospitals in Egypt from June 2006 to May 2008. Women with obstetric hemorrhage (estimated blood loss >or=1000 mL and/or >or=1 sign of shock [systolic blood pressure <100 mm Hg or pulse >100 beats per minute]) were treated with either a standardized protocol (pre-intervention) or a standardized protocol plus the NASG (intervention). The primary outcome was extreme adverse outcome (EAO), combining maternal mortality and severe morbidity (cardiac, respiratory, renal, or cerebral dysfunction). Secondary outcomes were measured blood loss, urine output, emergency hysterectomy, and (individually) mortality or morbidity. Analyses were performed to examine independent association of the NASG with EAO. RESULTS: Mean measured blood loss decreased from 379 mL pre-intervention to 253 mL in the intervention group (P<0.01). In a multiple logistic regression model, the NASG was associated with reduced odds of EAO (odds ratio 0.38; 95% confidence interval, 0.17-0.85). CONCLUSION: The NASG, in addition to standardized protocols at tertiary facilities for obstetric hemorrhage and shock, resulted in lower measured blood loss and reduced EAO.

Recurrent biparental hydatidiform mole: additional evidence for a 1.1-Mb locus in 19q13.4 and candidate gene analysis.

OBJECTIVES: A maternal autosomal recessive mutation causing recurrent biparentally inherited complete hydatidiform moles (BiCHM) in affected women was previously mapped to a 12.4-cM interval in 19q13.4, which was recently further narrowed to a smaller 1.1-Mb region at the centromeric end. It is believed that the mutant gene in this condition is a major contributor to the regulation of imprinting in the maternal germline. To confirm and possibly narrow the critical interval we studied additional rare familial and recurrent cases. METHODS: Using polymorphic marker analysis, we first confirmed biparental inheritance on the studied molar tissues. We then performed targeted homozygosity mapping with markers in 19q13.4 on DNA from affected women of a new large consanguineous pedigree, an additional potentially familial case, and three cases with sporadic recurrent CHM. Direct sequencing of coding exons and Southern analysis with a coding-region probe for one candidate gene (NALP5) was also performed. RESULTS: Biparental inheritance was confirmed for those molar tissues available for analysis. All women, except for one of the isolated cases, were homozygous for markers in the identified 1.1-Mb region in 19q13.4. No mutations or large genomic rearrangements were found in NALP5 (MATER), a gene with oocyte-specific expression. Heterozygosity for a single-nucleotide polymorphism in exon 13 of NALP5 in one patient may refine the candidate region to 1.0 Mb. CONCLUSIONS: The reported candidate region for BiCHM in 19q13.4 was confirmed in additional families, further establishing it as the major locus that harbors a gene mutated in this condition.

Female genital cutting: types, motives and perineal damage in laboring Egyptian women.

OBJECTIVES: To study the prevalence of female genital cutting (FGC) in a nulliparous population admitted for childbirth. In addition, the type of FGC, the motives supporting FGC and perineal damage associated with this practice were evaluated. SUBJECTS AND METHODS: A prospective cross-sectional study was conducted in the labor ward, Department of Obstetrics and Gynecology, Assiut University Hospital, Assiut, Egypt. Two hundred and fifty-four primigravid women in active labor were recruited over a period of 20 months. The subjects responded to a questionnaire and obstetric and pelvic examinations were carried out. The type of cut (circumcision) and extent of tissue removal were recorded. Data was gathered concerning possible motives for FGC, rates of episiotomy and incidence of perineal tears. RESULTS: All women recruited had been circumcised; 51% had type I cut and 49% had type II. Adherence to tradition was the most common motive for the operation (46.5%). Ninety-five percent of the study population had an episiotomy. The incidence of perineal tears was 1.6%. CONCLUSIONS: Female genital cutting (only types I and II) was confirmed in all patients in the study. There was a low incidence of perineal tears and a high episiotomy rate (95%). Episiotomy should be performed in all cases where FGC has made the vulva/vagina inelastic.

Habitual complete molar pregnancy: a case report.

Gestational trophoblastic disease is rare in industrialized countries. Rarer still are recurrent or habitual molar pregnancies. A rare case of hydatidiform mole occurring seven times consecutively without a normal pregnancy in an Egyptian woman is presented. She was first seen with her first molar pregnancy in 1994 at the age of 21 years. Subsequently, she had six consecutive molar pregnancies. The last was in October 1999; it was followed by a gestational trophoblastic disease. Each molar pregnancy was diagnosed ultrasonographically and confirmed by histopathological examination. Management of such patients is problematic especially when there is a desire for future childbearing.